Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Wednesday, February 06, 2008

The sub-blog post on the episodes of In Treatment where Laura, the patient, announces her love for her therapist, Paul, have gotten a number of comments. I fueled it with my subsequent post, You Don't Have To Say It All. I ended by saying that Paul needs to document what's going on, seek professional consultation, and end therapy with this patient.

Yup, if this were a real life case, it would be both upsetting and extreme.

I don't want to talk here about transference or counter-transference, they may feed into how things have played out, but psychodynamic terminology is not what the treatment setting is about at this point.

What is it about? I think it's about everyone's safety.

A quick recap. Laura is obsessed with her therapist. She's been seeing him for a year, she has a serious boyfriend who's proposed, she shows up to her first session after sitting outside in the dark for 4 hours, dressed in an outfit she'd worn to go to a bar and nearly have sex with a stranger in. She announces that she's in love with Paul, has been since the beginning. The next session, she arrives in her anesthesiologist uniform and announces her engagement along with her fears of becoming a domesticated animal (I may be reading too much into that). Paul is shocked at the engagement, less than enthused for her, asks why, when the week before she was presenting it as an unpleasant ultimatum, and Laura says, "I said yes because you said no." She talks about how Paul looked like a dead man when he first met her, implies she's brought him to life, pushes every boundary, and says--and please excuse my R-rated bluntness here-- "I want you to fuck me." We know from Paul's therapy session that his marriage is stale, that maybe his wife is unfaithful, that he is resisting looking at his own feelings towards Laura. We, as viewers, are probably meant to believe that Laura is just a bright young woman with a sixth sense and an ability to judge people. We hope and believe that she doesn't have have access to information about Paul's marriage and stale sex life (was she lurking at his session?), and because we know there's some truth there, it comes off a bit differently than if Laura said all these things but Paul was oh-so-happily married.

So here's the deal: there's a young woman who loves (real, transferential, does it really matter?) her psychotherapist and she's pushing for sex, for the bathroom inside the house, for a glimpse of his wife ("is she lying on the couch watching TV and drinking beer?"). She's raw and vulnerable, and she's decided to marry her boyfriend not because she loves him but because her psychotherapist won't have her. Perhaps she's angry, or desperate, or who knows what. But she's making a major life decision unwisely and tossing it onto the therapist (--seems to be a theme with Paul's patients). And she's not exploring her feelings with curiosity or respect for Paul's marriage, their doctor/patient relationship that absolutely forbids a sexual relationship, or as a therapeutic endeavor. She's saying "I want you to fuck me." She's trying, rather successfully, to make him uncomfortable, and right or wrong, she's making it about him and his needs/insecurities/feelings as well. Maybe she's got it right, or maybe she's projecting onto him her desire that he love her back (oops, I did it, I mentioned a defense mechanism, forgive the psychobabble). At any rate, we now know we have two raw, vulnerable, and hurting people and if this isn't a set-up for disaster....well, it is.

How does therapy continue from here? Does Laura even want to get better or is her goal to get laid? At any rate, she's been rejected from a pretty hard push proposition, and I'm guessing she's angry and her feelings are hurt. She's alone in an office with Paul, and so far we have no reason to believe that he's done anything unprofessional, and he's said point blank, "I'm your therapist, I'm not an option."

Laura has assured Paul that she won't boil his kids' rabbit. Oh good, but it's an unnerving reference to Fatal Attraction and violent unstable stalker women. It's not that I think Laura is a violent stalker woman, but I don't know and Paul may not know. At this point what I do know is that no one is safe.

From Paul's perspective, he could end up in bed with his patient--she's gorgeous and we know he's thinking about sex all the time. Such things unfortunately happen. This would not be a good outcome for anyone, it would ultimately injure the patient in unspeakable ways. Paul could also do everything absolutely right, continue to work therapeutically with Laura, refuse her advances, hold tight on reasonable therapeutic boundaries, and hope he can help her and that she has the strength to bear the pain of her unrequited love, to work in therapy, and to uphold the integrity necessary for the process. But these two people are alone together in an intimate setting-- if she decides to complain about her care, or to accuse Paul of any sexual wrong-doing, the issue becomes one of He Said-She Said and Paul's career, professional reputation, and marriage are a step away from ruin. The doctor isn't always in control-- when two people are alone together the issue of trust and safety goes both ways. The reality is that both the patient and therapist are vulnerable-- she is vulnerable to being used in a sexual way, he is vulnerable to the possibility of both his own misbehavior or that she might lie.

I've said that Paul needs to document what's going on, certainly for his own protection. He sought consultation, but he resisted talking about this patient. Now, however, with her new engagement, her statement of distress over his rejection, and her blatant "I want you to..." (oh, I've said it enough)... Paul needs to seek a consultation with more honesty. Do I think he should call Laura and dump her before the next session? Of course not. I do think they need to figure out what might make the sessions safe-- another person in the room would do it. Maybe Paul could borrow an office at a hospital clinic to see Laura in-- a little less intimate, two chairs, no couch. If he can get her to quickly cease her advances, to be willing to look at her feelings and the distraction and disturbance they create, and to address the issues of safety that they both now have, maybe it can be salvaged.

Please don't get me wrong here-- I'm not in any way saying that a psychotherapy needs to end if the patient becomes attracted to the doctor. It happens all the time. I'm not saying that it shouldn't be addressed in the therapy and looked at in whatever way works for both parties (--Hey, Tony professed his love for Dr. Melfi, lavished her with gifts, and moved on when she said "No, it's part of what happens in treatment.")

It's hard to get it to work, though, if it's more than a discussion of feelings. Laura's session was a full-court press for intercourse. In real life, these things end badly.

9
comments:

Anonymous
said...

All very good points but there is one more reason that the woman needs a new shrink and that is because the one she has is so screwed up that he did not see any of this coming."Don't tell me you didn't know." I find it tough to believe that she has been in love with the guy for a year but hasn't acted seductively so that he would notice until the f me scene. And the way she uses his name every 4 seconds, she has probably been doing that for a year and I don't think this guy has noticed what is going on and it is par to fhis job to pick up on things and this woman is not so subtle i bet there was plenty to pick up on a lot earlier and address before it got to this point. But by this point, you are right, it doesn't matter one bit where her "issue" is coming from because the the train has jumped the tracks already and I think that Dr W oh excuse me, Paul, needs a good long break to chill.

Hrm, perhaps he needs some time in that "freezer" that Alex was in. Just kidding, I am not wishing a heart attack on him, although this is a "heart" attack of a different sort.

Dinah, this was very enlightening, especially the early parts of the post (not that the rest wasn't good, but the first parts kinda connected the dots for me on something that I couldn't put words to, at least as far as I had gotten on my opinion of the matter. Your opinion goes further (well, you are a psychiatrist and I'm not! lol) and it's like pulling up that bridge in Indiana Jones 2 (Ugh, hate all the ickyness in that movie, but it did have it's moments), pulling the broken end back up with a rope to the other side.

Ie, it makes sense now, from two different thought paths I had on the matter, what you said was the connecting pieces that just FIT and helped me understand what you were getting at in the earlier post too, besides understanding more some of what's going on in the show.

Now THIS is awesome; it's added to my understanding of the complicated stuff going on, on top of yet more layers of deliciously complicated stuff later in the week.

Delicious in that, I don't enjoy anyone's discomfort, but in the sense of, well, this is just a show, and of course I wouldn't be saying this about the Sophie situation given the issues involved there and that that's a child portrayal, but as far as adults are concerned, with issues as and in adulthood, yeah layers of plot twist and additional things layered on to various relationships between the adults, that's what I mean.

If that makes any sense. I don't delight in emotional pain or anything, but one watches these things because they're interesting. Heck, I don't have to apologize, that's why they air the show.

Although I'm hoping they also air the show in part to bring light to certain issues, such as with Sophie.

Great post, Dinah.

Oh, and Clink, I just love the image of you fritterin' away your time, I mean, I donut know what you were doing (hee hee).

I also hope you know, Clink, that I really enjoy your posts; not that I think you so fragile I need to reassure you, but just because I wanted to say so! Plus, I donut know what we'd do without your perspective, either.

And yay, Roy popped in, and is working on World War III, I mean, the Benzo Wars podcast (hee hee.)

Hey, Roy. I don't know if you are still gonna be watching Lost, but it sure is interesting . . . (Dinah, you watching or saving this to watch later too?)

It just ocurred to me that maybe they can't get rid of Laura on the show. After all, who would be Monday's patient if they dumped her off the show by Paul ending therapy sessions with her?

I truly hope that things don't take a lurid turn. I also hope that it doesn't become a legal drama because he gets sued. I enjoy a nice quiet show with good dialogue, writing and acting and no explosions or bloody decapitation scenes.

Whew..

Dinah, I kind of have to agree with Anon. When I first read your post on Laura, I thought she came on to him at her first session. I did not realize she had been seeing him for a year.

Anon, Paul obviously has his head up his a** with everything we know about Kate and his kids, so perhaps it has affected his practice as well.

BTW, his office is HIDEOUS! It looks like a thrift store. Uh, so cluttered. You know what they say about your environment influencing you and you being influence by your environment. The clutter, disarray, utter randomness of decor and ugly furniture--what could they be saying about Paul's staid, settled ways?

Oh, and I forgot to mention (lol) I agree w/ anonymous, if that didn't come across . . . . I think though he was fooling himself (perhaps subconsciously) on Laura's desire just as he was on marital stuff with his wife; he's picked up on much, much more subtle (to me) things with other patients.

And then Lily posted while I was posting!! I agree, Lily. And that office is HUGE; I think it says something about how Paul keeps alot of "himself" in there, as far as the doodads, knick knacks, and books on his interests like photography (well, ok, so there's alot of bookshelves, why wouldn't he keep those there, but still). It's a space that's rather rambling and unrestricted and unconfining; perhaps in contrast to some of his feelings about his wife, marriage, etc?

His patients can do laps while he talks to them; get your exercise AND your therapy all at the same time, for the price of one! Woohoo, a new type of practice . . . . of course, no horizontal exercise allowed. That means YOU, paul and laura.

okay everyone, the office is huge because this is tv and on tv everyone lives in a rambling place even if they are a paralegal and they live in nyc where it would cost more in rent than they earn in ten years. and the office is not so much hideous as it goes with his brogue. it is brogeous.it is not new york (or whatever stand in) chic, but rumpled like he is and i have no idea what the thermostat is set to but i do not find him hot at all. he is like a crusted over bowl of oatmeal left in the kitchen sink.

Precisely. And it is because we usually see these hyperneat spaces that this cluttered space is so unusual and, in my opinion, significant. C'mon! Did you see that hideous pirate shot glass/demitasse cup or whatever it was? The set decorator was given some specific instructions, fer sure.

We're just having a bit of fun.

I have had therapists with huge offices and separete entraces/exits, but always in offices.

Paul can afford the square footage. After all, it is his home and he can write the office off on his taxes.

Has anyone become aware of how beautiful the outside views of the house are? It was in the married couple's session that you see the gorgeous ivy trailing over a white arbor and white fence...reminds me of the metaphone of "the picket fence."

Anyway, there are forums on the HBO site for anyone interested. We aren't the only ones obsessed!

IT IS ALWAYS THE psychiatrists job to set and maintain boundaries in the relationship!!

Paul has totallly f*cked up here!! he has failed to spot his patients issues, address them and resolve the problem. He has also acted seductively towards her, thereby fuelling her fantasy of him.

He is totally 100% liable, both morally and legally. It does not matter what Laura said, it's up to him, to tell her the truth about his sham of a marriage..., but then add that there can not be a rel between them....EVER.

He's a shit whio has used her vulnerabilities and LED HER ON !!!!SHAME ON HIM!!!